Loading...Download Veterinary Pet Insurance (VPI) Claim Form. This is a claim form for VIP Pet Insurance Company. This form is used to file a claim for any pet who is covered under one of their policies, whether it is for a pet wellness check up, illness or injury.
How To Write
Step 1 – Section 1 – Policyholder Information – Complete as follows:
- Policy Number:
- Pet Name:
- Name:
- Address:
- City:
- State:
- Zip:
- Home Phone Number
- Work Phone Number:
- Email:
Step 2 – Section 2 – Claim Details –
- Reason for visit (check all that apply):
- What injury or illness did your veterinarian diagnose? ( place diagnosis information in the block provided)
- Treatment Dates:
- From: mm/dd/yy To: mm/dd/yyyy
- Hospital or Clinic Name:
Step 3 – Section 3 – Invoice(s) Total
- You must submit itemized invoices with your claim form. Do not send estimates (this will delay or deny claim processes)
Step 4 – Section 4 – Policyholder Signature and Date
- Read the following prior to signing this form:
- By Signing this claim form, I confirm that to the best of my knowledge the information I have provided is true and correct. I authorize my veterinarian to release medical records and give consent to the Veterinary Pet Insurance Company in California and DMV Insurance Agency in all other states to communicate with my veterinarian or veterinarian’s staff.
- If you agree provide signature:
- Signature and Date mm/dd/yyyy
Step 5 – Section 5 – Submit Claim and Invoices:
- Submit your claim by only one method, duplicates will only cause delays in claim processing.
- Be certain to enclose all invoices.
- Fax to: 714-989-5600 – No Cover Sheet Is Necessary
- OR
- Mail to: VPI Claims Department
- PO Box 2344
- Brea, Ca 92822-2344